May 21, 2014

The Veterans Affairs Scandal Was Decades in the Making

Yes, you should be angry. But at whom?

It’s been more than six months since CNN and then the Arizona Republic began reporting about veterans dying while they were waiting for medical services—in some cases, on secret lists that clinics were maintaining to hide the long delays from authorities in the Department of Veterans Affairs. It’s not clear how many of these people died because they were waiting for care. An initial examination of 17 deaths, in Phoenix, suggested that none were the product of delays. Then again, it's not clear how much such nuance should matter. People who really need medical care shouldn’t have to wait for it, especially when those people have served their country. Everybody in Washington seems angry. For a change, they should be.

But angry at whom? It's hard to be sure right now. Conservatives say this story is proof that big government bureaucracies are prone to failure—and that Obama has failed to create the "21st Century V.A." he promised as a candidate. Both claims seem credible but, even together, they also seem incomplete. The process for getting veterans into the government's health system—and then getting them seen by VA medical professionals—has a long history of problems, dating back decades. And while the Obama Administration obviously hasn't solved them, it's presided over significant improvements in these and other areas of veterans services—at a time when the need for care from wounded veterans is growing.

Some of the best reporting on the scandal has come from Jordan Carney and Stacy Kaper of National Journal. As their stories point out, the struggle to make sure veterans get the assistance and care they need dates at least as far back as the presidency of John F. Kennedy. There have been ups and downs, frequently set off by surges in demand. In the 1990s, for example, federal lawmakers changed eligibility guidelines, so that all veterans—not just those with service-related disabilities or low incomes—were eligible to get medical services at government-run veterans’ clinics. That flooded the system and caused delays.

In 2001, the General Accounting Office issued a report warning that wait times for medical services at VA clinics were excessive—and dangerous. Since that time, wars in Afghanistan and Iraq have created a whole new generation of veterans. Advances in battlefield medicine have allowed more fighters to survive serious injuries, but that has also meant more returning home with wounds and disabilities, both physical and mental. Even though the total number of veterans has been declining, as the World War II generation passes on, the number of veterans seeking care has been increasing—placing further strains on the system. As my colleague Alec MacGillis has noted, the lawmakers screamingly most loudly right now seem blissfully unaware that the need for VA services is a direct by-product of wars they supported even more enthusiastically.

But demand alone doesn’t explain the VA's problems. Antiquated, sclerotic bureacracies are also part of the story. Veterans who wish to use VA health services must first apply. They also must get determinations about what kinds of disabilities they have—and how they got them. Those determinations are important: Veterans who lost limbs in battle, for example, get priority for services over those who served stateside without injury. The application files are still on paper, creating a huge backlog. The process also inflates wait times for actual medical services, since the disability determinations frequently require tests and checkups at VA medical facilities.

As a candidate in 2008, Obama talked about the toll these processes were taking on veterans. “It’s an outrage,” Obama said in one speech. “It’s a betrayal … of the ideals that we ask our troops to risk their lives for.” And the Administration has done a lot more than the tone of the current media frenzy might suggest. The transition from paper to electronic eligibility records is underway. That application backlog is down by 44 percent, at least according to official figures. Meanwhile, the Administration has eased eligibility for victims of Agent Orange and post-traumatic stress disorder—changes veterans advocates had sought for decades.

Those changes may have added to the system’s burden, creating the same kind of strain that took place in the 1990s. But Obama and allies like Bernie Sanders, chairman of the Senate Veterans Affairs Committee, have also fought for and secured substantial increases in the VA’s budget. The Administration has also presided over innovations, such as the opening of new outpatient clinics and the introduction of tele-medicine. These projects are expanding the VA’s reach at relatively low cost, while preserving its commitment to high-quality medicine. (The actual care at the VA remains top-notch, by most accounts, once people get it.) Oh, and a plan to reduce homelessness among veterans seems to be working. It's down by 24 percent.

Still, some reform efforts really have been slow—painfully slow. Back in 2012, the GAO issued another report warning that the VHA had poor, unreliable systems for making appointments and for tracking how long veterans are waiting for care at particular facilities. Among the problems: Staff were confused about how to use the system, in part because training was shoddy and training material was ambiguous. VA officials promised to fix things—and then didn’t. That same system is at the center of the current scandal. “You know, to be quite frank, it’s been more than a year and half,” Debra Draper, author of the GAO report, said during congressional testimony last week. “We would’ve expected more progress to be made.”

Plenty of smart people express similar sentiments—and wonder whether VA leaders grasp the sense of urgency. "By all accounts, [VA Secretary Eric] Shinseki is a fine man who has spent nearly six years lost in the system," Time's Joe Klein wrote in a blistering column. "An effective leader would have gone to Phoenix as soon as the scandal broke, expressed his outrage, held a town meeting for local VA outpatients and their families—dealt with their fury face-to-face—and let it be known that he was taking charge and heads were going to roll."

For now, the Administration's most immediate priorities are to figure out what happened in Phoenix and at other facilities, to hold the right people accountable, and to do whatever it can to help veterans currently waiting for services. But there are also ideas for longer-term, systemic reforms. When it comes to those disability determinations, for example, Linda Bilmes, an expert on veterans issues at Harvard’s Kennedy School of Government, has recommended scrapping the existing system. The government already approves 90 percent of claims from newly returning veterans, she says, so why not approve them all—and then audit a representative sample retroactively, in order to reduce fraud? Several officials have endorsed the idea and pilot versions are under discussion. But, Bilmes says, the VA couldn’t make such a wholesale change without broader action from officials and lawmakers. That hasn't happened yet.

Of course, it's worth remembering that some of the problems veterans are having right now have very little to do with the VA and a whole lot to do with American health care. As Phil Longman, author of Best Care Anywhere, noted in his own congressional testimony last week, long waits for services are actually pretty common in the U.S.—even for people with serious medical conditions—because the demand for services exceeds the supply of physicians. ("It took me two-and-a-half years to find a primary care physician in Northwest Washington who was still taking patients," he noted.) The difference is that the VA actually sets guidelines for waiting times and monitors compliance, however poorly. That doesn’t happen in the private sector. The victims of those waits suffer, too. They just don’t get the same attention.